CODE OF CONDUCT FOR EMPLOYEES – DECLARATION OF INTERESTS

This form should be completed and signed by all new employees and those accepting new contracts of employment. This form must be returned after the selection process but before you start work.

Please read the Staff Guidance Notes before completing this form.

Please print clearly in black ink

Name: ...........................................................................................................

Work Address: ..............................................................................................

Directorate: ...................................................................................................

Ext No: ..........................................................................................................

PART A

1. Employment

1.1 I am applying for: Job Title ..................................................................

Post Ref .................................................................................................

Additional Work (see paragraph 7 of the Code of Conduct)

2.2 I also work as:

Name and nature of business

3.3 Self-employed

I am self-employed as:

I trade under the following name(s) 2. Directorships (see paragraph 7 of the Code of Conduct)

2.1 I hold the following Directorships in the following companies:

FINANCIAL INTERESTS

3. Shareholdings (please see staff Guidance Notes paragraph 2.3)

3.1 I or my nominees own shares in the following companies:

4. Grant Aid (Please see Staff Guidance Notes paragraph 2.4)

4.1 I have recently applied or intend to apply for a grant on my own behalf from Barnet Council

YES / NO

If ‘YES’ specify nature and amount.

4.2 A group or organisation in which I am involved in the running (and in the decision making process) has applied for and/or intends to apply for a grant from Barnet Council

YES / NO

If ‘YES’ specify nature, amount and your position in group/organisation. PART B – Personal Interests of Employee

1. Clubs, Associations and Societies (Please see Staff Guidance Notes Paragraph 2.5)

1.1 I have a personal interest in or membership of the following clubs, associations and societies which has the potential to conflict with the interests of the Council.

(If you believe conflict of interest may exist state name and nature of any local clubs, associations and societies in which you have a personal interest/membership, including any chamber of commerce, trade association, rotary club, friendly society, townswomen’s guild, Royal British Legion, Inner Wheel, Round Table, Lions, TOCH, Special interest society, Amenity Society, Cultural Association, any other Charitable body and any other social clubs or societies).

2. Professional Bodies (See Staff Guidance Notes paragraph 2.6)

2.1 I am involved in the decision making process of the following bodies: (Please state name, nature of any professional body/bodies in which you are a member).

3. Select Societies (Please see paragraph 8 of the Code of Conduct)

3.1 I have a personal interest in/or membership of a select society: (Please state name and nature of any select societies in which you have a personal interest/membership, such as Freemasons, Knights of St Columbus.) I am involved in the running of a select society and in the decision making process. YES / NO

If ‘YES’ specify nature of role.

4. Housing Association (Please see Staff Guidance Notes paragraph 2.7)

4.1 I am a member of a Housing Association. YES / NO

If ‘YES’ specify name(s) and registered office(s):-

4.2 I am a member of a Tenants/Residents’ Association in the Borough of Barnet. YES / NO

If ‘YES’ specify name(s) of associate(s):-

5. Other Interests (Please see Code of Conduct paragraph 7)

5.1 I or my partner are associated with a limited company YES / NO

Specify nature of association 5.2 I am involved in the decision making process of a charitable trust

YES / NO

If ‘YES’ specify which trust and nature of relationship with the trust

I have another interest which may impact on my work

YES / NO

Please specify

5.3 I have been appointed by a Government Minister as a member of a statutory undertaking or other body which is constituted in order to discharge or assist in discharging a statutory function.

YES / NO

If ‘YES’ specify body(ies):

5.4 I am a Councillor in a Local Authority

YES / NO

If ‘YES’ specify which authority: 5.5 I am a co-opted member of a Local Authority Committee(s) or Sub-Committee(s)\
YES / NO

If ‘YES’ specify which authority(ies) and which committee(s):-

5.6 I am a member of a school governing body in the Borough of Barnet\
YES / NO

If ‘YES’ specify school(s):-

5.7 I am on the controlling body of a parent/teachers association in the Borough of Barnet\
YES / NO

If ‘YES’ specify which association(s):-

5.8 I am a Board member of a Hospital trust/Health Authority\
YES / NO

If ‘YES’ specify Hospital/Health Authority:- 5.9 I serve as a Magistrate (in Barnet or neighbouring area) YES / NO If ‘YES’ specify which Court:-

6. Recruitment of Relatives (Please see Staff Guidance Notes paragraph 2.9)

Are you related to/or have an association with a Member of the Council or anyone working for the Council YES / NO If ‘YES’ specify name(s) and work area(s)

Please see Guidance Note for Staff re: inspection of information (Paragraph 7).

I declare that to the best of my knowledge and belief the answers given above are truthful, accurate and complete. I undertake to inform my Director of any change to these answers within 28 days of that change taking place.

Signed .............................................................. Date ..................................

When completed, please return this form to HR who will forward it to your Chief Officer

FOR OFFICE USE

Noted by Director/Divisional Head ..............................................